Student Health Quote Request Form

Enter the information requested below, along with the Age(s) of insured plan members to be included in this proposal.
NOTE: Items with a * are required

First Name:

Last Name:

Email: *

Zip: *

Daytime Phone:

Gender

Date of Birth

Height

Weight

Tobaco User?

Full-time
Student?

Applicant:

Spouse:

Child:

Child:

Child:

Child:

Child:

Requested Effective Date
September
October
November

Maternity Coverage

What is your current health plan premium?
(optional)

$
a month

Show
All (Plans With & Without Maternity Coverage)

Only
Plans With Maternity Coverage

Medical
Plan Type

Standard
Individual & Family Coverage

Short-Term,
Up to 12 Months of Temporary Coverage

Online
Quote Instruction Guide

Family Members To Be
Insured

You can apply for any one of the following combinations of family members:
ï¿½ Single adult
ï¿½ Couple - you and your spouse
ï¿½ Family - you, your spouse and one or more children
ï¿½ Single parent household - parent and one or more children
ï¿½ Single child
ï¿½ More than one child

The gender and age/date of birth of each person is also required.

When entering a child and/or children only, enter the age/date of birth in the child
boxes. Enter any additional children in the appropriate
child blocks. Rate computations for child/children only plans vary by
carrier. Some insurance companies have specific rates for youth plans
and other insurance companies base rates for children on the age of
either the youngest or oldest child.

Age/Date of Birth - The age or date of birth for each family member that is to be insured.

Tobacco Usage - For each adult that is to be insured, please
check the box if they are a tobacco user. By default, all adults are
assumed to NOT be tobacco users.

Medical Plan Types

Medical, standard long-term coverage
Most people select this form of coverage. This type of coverage can be
renewable for multiple years and can provide continuous claims
coverage over a long period of time. Most plans of this type cover
both major medical expenses (e.g., hospitalization and surgeries) and
routine medical expenses (e.g., office visits and annual exams),
subject to deductibles and co-payments or co-insurance.

Short-term, up to 12 months temporary coverage
Short-term health insurance is a temporary health insurance plan
(typically 1 to 12 months) and should NOT be used as a substitute for
standard, long-term health insurance.

Short-term health insurance may be right for you if you are:

Between jobs

Waiting for coverage from another health plan to start

Laid off

On strike

A recent college graduate

A seasonal employee

BUT, please keep in mind the following:

Short-term medical plans are intended as interim or
"gap" coverage, i.e., for people who know, with
certainty, that they will have standard, long-term coverage (or
coverage through an employer) at a future date.

Short-term plans are designed to provide protection from
unforeseen illness or injury; they are not meant to cover routine
exams, preventive care, dental or eye care, or immunizations.

Short-term plans are exempt from HIPAA legislation. This means
that when issuing a Short-term medical policy, insurance carriers
do not have to: guarantee renewal, guarantee issue, or waive the
pre-existing condition limitation for federally eligible
individuals.

Most importantly, short-term medical plans provide coverage for
a limited time frame only. Once this time frame ends, you may or
may not be able to buy additional health insurance, depending on
your health at that point in time.

IF YOU ARE UNSURE THAT YOU WILL HAVE STANDARD, LONG-TERM HEALTH
INSURANCE (OR INSURANCE THROUGH AN EMPLOYER) WITHIN 12 MONTHS, WE
STRONGLY RECOMMEND THAT YOU VIEW PLANS FOR STANDARD, LONG-TERM HEALTH
COVERAGE NOW, BEFORE THERE IS AN ADVERSE CHANGE IN YOUR HEALTH
CONDITION.